1. What are the purposes of a health history?
    To collect subjective and objective data. The history is combined with objective data from the physical examination and laboratory studies to form the database.
  2. What is subjective data?
    Its what person says about himself or herself
  3. What is objective data?
    Is what you observe through measurement, inspection, palpation, percussion and auscultation.
  4. What is the purpose of review of systems?
    3 total: - to evaluate the past and present health state of each body system - To double check in case any significant data were omitted in the �present illness section� - to evaluate health promotion practices.
  5. What is sought after in the biographical data?
    Name, address, DOB, age, sex, marital status, race, ethnic origin, occupation
  6. What is sought after in the source of history?
    Record who is furnishing the information
  7. What is sought after in the reason for seeking care?
    Brief spontaneous statement in the person�s own words that describes the reason for the visit
  8. What is sought after in the present health or history of present illness?
    What is going on with them. Their general state of health. For the ill it�s a chronologic record of the reason for seeking care.
  9. When a person is telling you about any symptoms they are experiencing it should include eight critical characteristics. What are they?
    Location, Character or Quality � burning, sharp, dull, aching; how intense, Quantity or severity � pain on a scale of 1-10, Timing � onset, duration, frequency, Setting � where or what was the person doing when the symptom started, aggravating or Relieving Factors � what makes the pain worse, Associated Factors � is the symptom associated with anything else, Patient�s perception � how has this symptom affected you
  10. What is sought after in the past history?
    Past history is important because they may have residual effects on the current health state; accidents, hospitalizations, allergies, current meds
  11. What is sought after in the family history?
    This will highlight those diseases and conditions for which a particular patient may be at increased risk
  12. An acronym for the 8 critical characteristics for present health
    P � rovocative what brings it on, Q � uality how intense, R � egion where is the pain or issue, S - everity, T � ime onset, U � nderstand patient�s perception
  13. What is sought after in the review of functional assessment?
    Measures the person�s self care ability; ADL � activities of daily living
  14. What is sought after in the perception of health?
    How do they define health?
  15. What are some developmental considerations during a health history for an older adult?
    Take your time since they might be hard of hearing, visual loss, loss of mobility
  16. What is a genogram?
    A graphic family tree that uses symbols to depict the gender, relationship and age of immediate blood relatives in at least three generations.
  17. What do some of the symbols mean in a genogram or family tree?
    A square represents a male, circle is female, a square with a diagonal line through it means a person died.
  18. What are the 4 physical exam techniques?
    Inspection, palpation, percussion, and auscultation
  19. What is the reason you use inspection technique during assessment?
    Purpose: general survey of the patient, concentrate on watching, When: 1st moment you meet the patient.How: use senses � sight, smell touch hearing, its always done 1st before any of the other techniques
  20. What is the reason you use palpation technique during assessment?
    Purpose: touch � determine texture, size, consistency and location of body parts, When: Two types � light and deep. Light accustom patient to being touched. Deep � abdominal area, How: fingertips for fine tactile. Finger and thumb � position shape and consistency of an organ/mass. Dorsa of hand � to check temp.
  21. What is the reason you use percussion technique during assessment?
    Purpose: Assess location size and density of underlying structures.When: since x-rays are not always readily available your hands always are, easy portable and give instant feedback, How: the art of striking one object against another to create sound
  22. What is the reason you use auscultation technique during assessment?
    Purpose: listening to sounds produced by the body using a stethoscope � pitch, quality, loudness and duration, When: when you cant hear with your ear alone, How: using the stethoscope listen to the heart, blood vessels, lungs abdomen, blood pressure.
  23. Sounds of indirect percussion over normal lungs?
  24. Sounds of indirect percussion over stomach intestine abdomen?
  25. Sounds of indirect percussion over bone or tumor?
  26. Sounds of indirect percussion over organs?
  27. What are the four areas of a general survey?
    Physical appearance, body structure, mobility, and behavior.
  28. What information is obtained during a general survey of physical appearance?
    Age, gender, facial features
  29. What information is obtained during a general survey of body structure?
    Nutrition, symmetry, obvious physical deformities.
  30. What information is obtained during a general survey of mobility?
    Gait and range of motion
  31. What information is obtained during a general survey of behavior?
    Facial expression, speech, dress, personal hygiene
  32. What are the various routes of temp measurement?
    Oral, electronic thermometer, axillary, rectal, tympanic membrane thermometer
  33. What is the special consideration for checking temperature orally?
    Quick, accurate and convenient
  34. What is the special consideration for checking temperature with an electronic thermometer?
    Quick, accurate, unbreakable, disposable probe covers
  35. What is the special consideration for checking temperature axillary?
    Safe and accurate, for infants young children
  36. What is the special consideration for checking temperature rectally?
    Used when other routes are not practical ie. Cant close mouth
  37. What are the 4 qualities considered when assessing a pulse?
    Rate normal for an adult 60-100, Rhythm normal is an even tempo, Force full normal weak and absent, Elasticity springy, straight
  38. Appropriate procedure for assessing normal respirations
    Assess while person is unaware, count for 30 secs unless abnormally
Card Set
assessment study guide exam 1